1114919677 NPI number — DR. CAROLYN K KHA OD

Table of content: DR. CAROLYN K KHA OD (NPI 1114919677)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114919677 NPI number — DR. CAROLYN K KHA OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KHA
Provider First Name:
CAROLYN
Provider Middle Name:
K
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114919677
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4927 LAKE RIDGE PKWY
Provider Second Line Business Mailing Address:
SUITE NUMBER 160
Provider Business Mailing Address City Name:
GRAND PRAIRIE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75052-3073
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-641-5900
Provider Business Mailing Address Fax Number:
972-641-5903

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4927 LAKE RIDGE PKWY
Provider Second Line Business Practice Location Address:
SUITE NUMBER 160
Provider Business Practice Location Address City Name:
GRAND PRAIRIE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75052-3073
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-641-5900
Provider Business Practice Location Address Fax Number:
972-641-5903
Provider Enumeration Date:
08/19/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  6592TG , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6592TG . This is a "TX OPTOMETRY BOARD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 90136629 . This is a "DPS REGISTRATION" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".